It was hard to miss the loud rumbles in November. In a reversal of its 2002 recommendations, the U.S. Preventive Services Task Force (USPSTF) issued new guidelines last month recommending against routine screening mammography in women aged 40 to 49 years and advocating screening only every two years for women aged 50 to 74 years. The uproar reverberated across the nation and shook up the nation’s Capitol, as well.
“Scientifically unfounded,” “contrary to the evidence” and “incredibly flawed” are just a few of the outcries from the radiology community pertaining to the suggested new guidelines.
“Over the past 17 years, I have routinely diagnosed women in their 40s on a screening or diagnostic mammogram,” says Stamatia Destounis, MD, from the Elizabeth Wende Breast Care Center in Rochester, N.Y.
After reviewing the center’s data for the last five years, Destounis found a relatively equal number of breast cancers in patients in the age groups 40 to 49, 50 to 59, 60 to 69, and 70 and above. “We found about 25 percent in each category, a considerable number of those detected through screening mammography,” she says. “The recommendation to start screening at age 40 is not empirically derived. The reality is that in the last two decades, we have seen a decrease in mortality from breast cancer, when prior to 1990, the death rate had been flat for many years.”
Despite the USPSTF’s connection to the Department of Health and Human Services (HHS), HHS Secretary Kathleen Sebelius was forced to make several announcements shortly after the release of the new screening recommendations to quell the chaos and confusion felt by women and providers. “The U.S. Preventive Services Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don’t determine what services are covered by the federal government,” Sebelius said at a press conference. “Indeed, I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action.”
But Tom Harkin, D-IA, chair of the Senate Health, Education, Labor and Pensions Committee, wants to investigate how the recommendations came into being, especially because the task force included representatives from health insurers, but not a single expert in mammography, breast surgery or oncology. Nearly two dozen senators wrote a bipartisan letter in support of Harkin. The American College of Radiology (ACR) has urged Harkin’s committee to allow a member of the ACR to testify at the hearing, which has not yet been scheduled.
Good science or bad policy?
The rallying cry from the breast imaging and radiology communities has been that the recommendations were based on bad science. Some even claim they amount to “healthcare rationing.”
Howard P. Forman, MD, MBA, a professor of diagnostic radiology, economics and public health at Yale University, says the underlying research of the task force is a “thoughtful decision analysis that incorporates the best data that currently exist.” The recommendations “tacitly, but not explicitly, acknowledge some cost issues,” Forman says.
The ACR has not sugar-coated its response. “We feel that the recommendations were cost-cutting measures made by people with no expertise in the subject matter that will cause countless women to die unnecessarily each year from breast cancer,” says Shawn Farley, spokesperson for the ACR. “The fact that insurance company staff were represented on the USPSTF, but not one cancer expert, just does not pass the smell test.”
The ACR issued a statement containing its scientific objections to the new screening recommendations. Among the objectives, the college said there is no scientific justification for choosing the age of 50 as a threshold for screening mammography.
“There are no data that show any of the parameters of screening change abruptly at the age of 50 or any other age,” according to the statement. “The USPSTF grouped women by decades, but it still made it appear as if something biologically important happens at age 50 when the age of 50 is nothing more than an arbitrary selection.”
Daniel B. Kopans, MD, director of breast imaging at Massachusetts General Hospital in Boston, says that the guidelines ignore most of the important scientific evidence and rely on unproven, computer modeling. “You might remember that there were very sophisticated financial computer models that said everything was rosy just before